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4d APPLICATION FOR SANITATION PERMIT (Complete in 'Duplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 5499.. JOB ADDRESS AND LOCATION-------- '-O Z-O- 'f 'rv_R__12T--- ------- r - ------ ,•� �f ,; Owner's Name-- LIQ p� lf� "---------- � . �.i� Phone_ fl1' ` Address-------------- - p -----_, �cvC -- ---------------------------------- ------;----------------------------------------------=--------------- k� �5�,i;'�1e.__ ----- -- Phone Q 7 Contractor's Name---�..�- ----�-- -- - '�"----- - .C!°�'�=�--- _ --�=� �-- --------- - -- Motel Other ❑ Installation will serve: Residence ❑ Apartment House ❑ Commercial K Trai�A o ❑ ❑ Number of living units: ❑ Number of bedrooms ❑ Number of baths® Lot'size------- _ _ _-DL-------- -- ---------------- I Water Supply: Public system ❑ Community system ❑ Private b Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: [No septic tank or cesspool permitted if public sewer is available within 200 feet.]- Septic Tank: Distance from nearest well_________________Distance from foundation--------------------Material------------------------------------------------- ❑ No. of compartments--------------------------Capacity-----------------------Size --------------------Liquid depth--------------------------- Cesspool: Distance from nearest well_________________Distance from foundation--------------.____ Lining material____------__________-- ____________- ❑ Size: Diameter--------------------------------------Depth-------------------------------------------- Privy: Distance from nearest well_____________________ ---------------------------Distance from nearest building-------------------------------------- -- ❑ Distance to nearest lot line___-------------------------------------------- Seepage Pit: Distance to nearest well-----SO__�_____Distant�,fro��jjfoundation___-_-�0_r__.Distanc��to nearest lot line___ "f--- --------Linin materiali�e�t__W_kvL__Size: Diameter------�-a3-" -----Depth-----,�Q ----------------- Number of pits---------�" g i Disposal Field: Distance from nearest well---1/ '__.Distance from foundation------ �_'_---__Distance to nearest lot line_ 1_Z__._ Number of lines-------------li-iir-- -_--- Length of each line_______ZZ-0 e-- ------Width of trench_______-___--_--- ------------ Type of filter material_-- ----— ---Depth.of filter material-------- - ; Remodeling and/or repairing (describe)__________________"_ - ✓ --------A&J- -------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------- hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws;an ules and regulations of the-San Joaquin Local Health District. P\ �� -- --_ _ -- Contractor (Signed)- --- a - - ____f --- - \ c� a - --f- �� j g • -------------------- --------- --(Title)- - � ------------ Y (Plot plan , s ng size of lo+, location of ys+em in relation to wells, buildings, etc., must be filed with this application]. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------------------------- DATE REVIEWED BY----------------------------------------------------- DATE------------ � ------------------------- BUILDINGPERMIT ISSUED------------------------------------ ---------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations------------------------------ -------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------- PERMIT NW---W. 0 ISSUED------ y �_ -------(Date) FINAL INSPECTION BY______________�_ -------- ---------------- -- ----------------- ate----------------- =- -------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Stockton, California ES-9-2M 9-50 W-1639